Inspection·February 11, 2025

F 0640 09/18/24, 24 days after completion. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/12/25 at 2:00PM, the MDS coordinator said she completed the MDS as required, but she had to wait for RN to sign as completed. She said she did not complete CR #81's MDS because CR #81 was a short stay Resident and the MDS was done by a staff that no longer work for the facility. She said not completing the MDS in a timely manner could result in care plan not being completed and delay in care and services as well as denial of payment for services by payer source. Residents Affected - Some During an interview with the Facility's Corporate MDS Coordinator on 02/12/25 at 3:40PM, she said the MDS staff had to wait for the RN signatures and that may result in the MDS being transmitted late. She said she would transmit CR #81 as soon as possible. During an interview with the DON on 02/11/24 at 4:00PM, she said she was not trained to sign the MDS and there was a Cooperate corporate staff that signed off on the MDS. Policy on MDS completion and transmission was requested on 02/11/25 at 4:00 PM. MDS coordinator said she follows the RAI manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 4 days out of 30 days (9/1/24 (Sunday), 9/14/24 (Saturday), 9/15/24 (Sunday), and 9/29/24() reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 9/1/24 (Sunday), 9/14/24 (Saturday), 9/15/24 (Sunday), and 9/29/24 (Sunday). This deficient practice could place residents at risk of not receiving adequate care by not having staff available with the ability to perform assessments as needed. Findings included: Interview with the DON on 2/11/25 at 2:14 p.m. revealed that she started with the facility on October 25, 2024, which revealed she was not working at the facility during September of 2024. The DON said that the DON would be RN coverage on the days they are working which would have been Mondays through Fridays. Interview with the DON on 2/11/25 at 2:57 p.m. revealed that RN G provided RN coverage for 9/1/24, 9/14/24, 9/15/24, and 9/29/24. The surveyor requested DON A to provide timecards for these dates. Interview with the Administrator on 2/11/25 at 4:01 p.m. revealed that human resources completed the PBJ report. The Administrator said that the human resources employee who completed the report in September of 2024 was no longer working at the facility. The Administrator said that there should be 8 hours of RN coverage per 24 hours. The Administrator said she was not aware of any problems with RN coverage prior to her starting at the facility in December of 2024. The Administrator said that there are two weekend supervisors which are RN I and she did not know the name of the other supervisor at the time of the interview. Interview with DON A on 2/11/25 at 4:06 p.m. revealed that RN I and RN J are the current weekend supervisors. On 02/11/25 at 4:09 p.m., an attempt was made to call RN J in attempt to obtain more information. RN J is a RN Weekend Supervisor per DON A interview, but there was no answer and the mailbox was full and voice message was unable to be left. On 2/11/25 at 4:09 p.m., an attempt was made to call RN I in an attempt to obtain more information. RN I is a RN Weekend Supervisor per Administrator and DON A interview, and a message was left with surveyor contact information. Interview with the ADON on 2/11/25 at 4:28 p.m. revealed that they said they were not aware of any previous problems with RN coverage. The ADON said they started with facility in December of 2024 which revealed they were not working at the facility in September of 2024. On 2/11/25 at 4:40 p.m., an attempt was made to contact Human Resources who was working during September of 2024 and a message was left with surveyor contact information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 2/11/25 at 4:41 p.m., an attempt was made to contact DON B who was working during September of 2024 and a message was left with surveyor contact information. Record Review of Nursing Time Detail Report 8.1.24 to 2.10.25 revealed during the month of September 2024 that RN J clocked in and out on 9/7/24, 9/8/24, 9/21/24, 9/22/24, 9/28/24 for at least 8 consecutive hours. No other RNs were seen as clocking in during the month of September including the dates of 9/1/24, 9/14/24, 9/15/24, and 9/29/24. Record Review of timecards for RN H for September of 2024 revealed they clocked in at 6 p.m. on 8/31/24 and clocked out at 6:30 a.m. on 9/1/24. RN H clocked in at 6:02 p.m. on 9/1/24 and clocked out at 6:30 a.m. on 9/2/24. There was not 8 consecutive hours of RN coverage on 9/1/24 as there was 6.5 hours from midnight to 6:30 a.m. and 5 hours and 58 minutes from 6:02 p.m. to midnight. Record Review of timecards for RN G for September of 2024 revealed that she clocked in at 6:17 p.m. on 9/14/24 and clocked out at 5:03 a.m. on 9/15/24. RN G clocked in at 9:26 p.m. on 9/15/24 and clocked out at 6:06 a.m on 9/16/24. RN G clocked in at 6:27 p.m. on 9/29/24 and clocked out at 1 a.m. on 9/30/24. On 9/14/24 RN G worked 5 hours and 43 minutes. On 9/15/24 RN G worked 5 hours and 3 minutes from midnight to 5:03 a.m. and 2 hours and 23 minutes from 9:26 p.m. to midnight which was not 8 consecutive hours. On 9/29/24 RN G worked 5 hours and 33 minutes. Record Review of Incidents By Incident Type report revealed the following information. On 9/1/24 there was one fall incident. On 9/15/24 there was one fall incident. On 9/19/24 there was one fall incident. On 9/29/24 there was one incident of physical aggression initiated and one incident of physical aggression received. On the dates of 9/1/24, 9/14/24, 9/15/24, and 9/29/24 there was not an increase in incidents documented when compared to the rest of the month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 1 of 8 residents (Resident #14) reviewed for dental services Residents Affected - Some The facility failed to ensure Resident #14 was referred to the dentist after complaining of tooth pain. The failure could place residents at risk of pain and decline in health. Findings included: Record review of Resident #14'sadmission record dated 11/18/2024 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnosis included pain, COPD, HTN and dementia. Record review of quarterly MDS assessment dated [DATE] for Resident #14 MDS reflected did not indicate any problems with oral health. Resident #14's BIMS indicated a score of 7 indicating severe cognitive impairment. Record review of Resident #14's care plan indicated the following: DENTAL CARE: Resident #14's has dental concerns and is at risk for increased pain and infections AEB broken teeth, Date Initiated: 06/26/2024, Revision on: 06/26/2024.Resident #14 will receive adequate nutrition/hydration, pain will be relieved with pain medications or other intervention and no signs of infection will occur over the next 90 days, Date Initiated: 06/26/2024, Revision on: 07/16/2024, Target Date: 10/08/2024. During observation and interview on 2/10/2025 at 9:00am. Resident #14 stated she had pain in her mouth and had not seen the dentist in sometime. Resident #14 stated she told the nurse and the SW of her pain and wishes to see the dentist. Resident #14 opened her mouth and she had some missing teeth and foul odor coming from her mouth. Resident #14 stated it is difficult for her to chew her food due to pain. In an interview with DON on 02/10/2025 at 9:45am, the DON said she was new and just started and she is getting to know the residents. The DON said all residents should be assessed upon admission for dental needs. DON stated that all needs should be discussed during care plan meetings. In an interview with DON on 02/11/2025 at 9:30am, the DON said she followed up with Resident #14's teeth after the surveyor made mention of concerns. The DON said she should have been referred to the SW by the nurse. In an interview on 2/11/2025 at 9:55am with LVN A she said she smelled Resident#14's breath when giving medication but thought she had bad breath. LVN A stated Resident #14 complained sometimes that her mouth hurt, and she would call the doctor and provide her with pain medication. LVN A said if residents need to see the dentist, she would tell the SW. In an interview on 2/11/2025 at 10:30am with SW she said she just returned to the facility from being out for 3 weeks due to injury. SW stated she was working on getting Residents seen by the dentist and she started working at the facility in November of 2024. SW said she was trying to play catch up from previous SW. SW said she was not sure if resident was on the list but can recall she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have the funds or something with her insurance that did not allow her to be seen. SW said if residents do not have the funds or something the facility will cover I think. In an interview on 2/11/2025 at 11:00am with facility Administrator, she said if Residents cannot pay for dental services the company will cover the cost for the resident if her or she is in pain. The administrator said she was not aware of Resident #14 needing dental services and all residents should be screened upon admission and if services is needed a referral is to be made. Record review of facility policy on dental services in admission agreement packet states the following: Dental Services: The facility does not provide dental services all dental services will be the responsible parties responsibility or paid through Medicaid services. Facility policy did not state if they would provide services for resident if dental services is needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's one of one only kitchen reviewed for kitchen sanitation. -The facility failed to label, and date left over foods items in 3 of 3 coolers in the kitchen. -The facility failed to ensure that food brought from home by staff were, label. dated and was stored in a designated refrigerator outside the kitchen. These failures could place residents at risk for food-borne illness and food contamination. The findings include: Observation and interview with [NAME] H on 02/09/25 at 9:15AM, revealed, -one of one stove in the kitchen revealed the door to the stove was broken and was held in place with a piece of cardboard. In an interview, cook H said the door had been broken for some times but did not say for how long. she said she could not answer the question. - Cooler #1 had left over coleslaw in a plastic unlabeled, dated 2-04-25 to 2-06-25. Left over Tuna in a plastic container unlabeled and dated 01/08/25. [NAME] H said that was a wrong date. -Cooler #2 had a pan of unlabeled and undated brown substance in a full-size baking pan. [NAME] H said, she I think it was some type of meat. Two unknown substances in a local grocery bag unlabeled and undated identified by [NAME] H as Resident's food. -Cooler # 3 had 4 serving sizes of left over pudding covered with plastic wrap unlabeled and undated. Two serving sizes of Jello covered with plastic wrap unlabeled and undated, one half open. All unlabeled and undated food items were identified by [NAME] H. She said all precooked, leftover food items and food products out of the original container should be labeled and dated by the person storing the food in the cooler, refrigerator or freezer for identification and safety. During an interview with the Dietary Manager on 02/10/25 at 3:30PM, she said the unlabeled and undated food items in a local grocery bag was for Dietary Aide M and he knows not to leave his food in the kitchen cooler unlabeled and undated. She said all food items out of the original containers should be labeled and dated with open date and expiration date for identification, used by date, for safety because consuming expired food items may result in food poisoning and food borne illness. She said the door latch to the stove had been bad around Christmas. She said she did not remember the date, but she told the Maintenance Manager that no longer worked at the facility. She said she did not write down the conversation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Dietary Aide M on 2/10/25 at 3:00PM, he said the food in the cooler was his left-over chicken and he would not keep his left over in the cooler. He said he would not do that again and walk away. During an interview with the facility's Administrator on 02/11/25 at 1:00PM, she said all food brought from home for residents was kept in a refrigerator in her office with label and date for a few days as specified by the family member. She said employees should not store their left-over food and food products in the kitchen refrigerator or cooler. Record review of facility policy titled Nutritional Services Policies and Procedures Revised 08/12/2019 reflected: Subject: Food Safety in Receiving and Storage read in part, It is the policy of this facility that food will be received and stored by methods to minimize contamination and bacterial growth. #3 Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents and the date it was transferred to the new container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 8 of 8